Developing a Framework and Electronic Tool for Communicating Diagnostic Uncertainty in Primary Care: A Qualitative Study.

Importance: Communication of information has emerged as a critical component of diagnostic quality. Communication of diagnostic uncertainty represents a key but inadequately examined element of diagnosis. Objective: To identify key elements facilitating understanding and managing diagnostic uncertainty, examine optimal ways to convey uncertainty to patients, and develop and test a novel tool to communicate diagnostic uncertainty in actual clinical encounters. Design, Setting, and Participants: A 5-stage qualitative study was performed between July 2018 and April 2020, at an academic primary care clinic in Boston, Massachusetts, with a convenience sample of 24 primary care physicians (PCPs), 40 patients, and 5 informatics and quality/safety experts. First, a literature review and panel discussion with PCPs were conducted and 4 clinical vignettes of typical diagnostic uncertainty scenarios were developed. Second, these scenarios were tested during think-aloud simulated encounters with expert PCPs to iteratively draft a patient leaflet and a clinician guide. Third, the leaflet content was evaluated with 3 patient focus groups. Fourth, additional feedback was obtained from PCPs and informatics experts to iteratively redesign the leaflet content and workflow. Fifth, the refined leaflet was integrated into an electronic health record voice-enabled dictation template that was tested by 2 PCPs during 15 patient encounters for new diagnostic problems. Data were thematically analyzed using qualitative analysis software. Main Outcomes and Measures: Perceptions and testing of content, feasibility, usability, and satisfaction with a prototype tool for communicating diagnostic uncertainty to patients. Results: Overall, 69 participants were interviewed. A clinician guide and a diagnostic uncertainty communication tool were developed based on the PCP interviews and patient feedback. The optimal tool requirements included 6 key domains: most likely diagnosis, follow-up plan, test limitations, expected improvement, contact information, and space for patient input. Patient feedback on the leaflet was iteratively incorporated into 4 successive versions, culminating in a successfully piloted prototype tool as an end-of-visit voice recognition dictation template with high levels of patient satisfaction for 15 patients with whom the tool was tested. Conclusions and Relevance: In this qualitative study, a diagnostic uncertainty communication tool was successfully designed and implemented during clinical encounters. The tool demonstrated good workflow integration and patient satisfaction.

Lessons Learned in Implementing a Chronic Opioid Therapy Management System.

OBJECTIVES: Opioid misuse has resulted in significant morbidity and mortality in the United States, and safer opioid use represents an important challenge in the primary care setting. This article describes a research collaborative of health service researchers, systems engineers, and clinicians seeking to improve processes for safer chronic opioid therapy management in an academic primary care center. We present implementation results and lessons learned along with an intervention toolkit that others may consider using within their organization. METHODS: Using iterative improvement lifecycles and systems engineering principles, we developed a risk-based workflow model for patients on chronic opioids. Two key safe opioid use process metrics-percent of patients with recent opioid treatment agreements and urine drug tests-were identified, and processes to improve these measures were designed, tested, and implemented. Focus groups were conducted after the conclusion of implementation, with barriers and lessons learned identified via thematic analysis. RESULTS: Initial surveys revealed a lack of knowledge regarding resources available to patients and prescribers in the primary care clinic. In addition, 18 clinicians (69%) reported largely "inheriting" (rather than initiating) their chronic opioid therapy patients. We tracked 68 patients over a 4-year period. Although process measures improved, full adherence was not achieved for the entire population. Barriers included team structure, the evolving opioid environment, and surveillance challenges, along with disruptions resulting from the 2019 novel coronavirus. CONCLUSIONS: Safe primary care opioid prescribing requires ongoing monitoring and management in a complex environment. The application of a risk-based approach is possible but requires adaptability and redundancies to be reliable.

A novel modality for real-time measurement of provider happiness.

Objective: Physician burnout is at epidemic proportions, impacts clinical outcomes, and is very costly. Although there is emerging data about effective interventions, most physicians at risk of burnout do not seek help. Survey-based measures exist which can quantify burnout within populations, but these are usually only administered episodically. We hypothesized that a novel modality for real-time measurement of happiness and stressors would be acceptable, scalable, and could provide new actionable insights. Materials: We developed a novel informatics system consisting of a networked smart button device, server, and analytics for measuring happiness, and stressors in real-time during clinical work. We performed an observational cohort study in 3 primary care clinics. Random and fixed effects modeling was used to analyze predictors of stress and happiness and we conducted a survey of usability and user acceptance of the novel system. Results: We captured 455 recordings across 392 provider days from 14 primary care providers. In total, 85% of users found the device easy to use, and 87% would recommend the system to their colleagues. Happiness and stressors were observed in all working hours of the day, with a 22% reduction in feeling (the proportion of happiness to stressors) across a clinical day. Discussion: We tested a novel system which providers found easy to use and enabled collection of detailed data. Limitations included being an observational study within a small number of clinics. A simple, unintrusive, scalable informatics system capable of measuring happiness, and stressors in real-time could be useful to healthcare organizations and teams.

Educational adaptation to clinical training during the COVID-19 pandemic: a process analysis.

BACKGROUND: The COVID-19 pandemic is unprecedented in terms of the extent and rapidity of the disruption forced upon formal clinical education, most notably the extensive transition of clinical skills learning to interactive video-based clinical education. METHODS: In a phenomenologic study, we used thematic analysis to explore the COVID-19 disruption to clinical training and understand processes relating to adaptation in a large academic medical center. We conducted semi-structured interviews with 14 clinical teachers and 16 trainees representing all levels of clinical learning. Interviews occurred within the initial three months of the crisis, and data were analyzed following a thematic analysis coding process. RESULTS: We constructed eight themes synthesizing our participants' perceptions of the immediate unanticipated disruption, noting in the process their alignment with a change management framework. These included: urgency in adapting, with an obvious imperative for change; overcoming inconsistent involvement and support through the formation of self-organized frontline coalitions; attempts to develop strategy and vision via initially reactive but eventually consistent communication; empowering a volunteer army through co-creation and a flattened hierarchy; and efforts to sustain improvement and positive momentum with celebration of trial, error, and growth. The majority of participants found positive outcomes resulting from the tumultuous change process. Moreover, they were now more readily accepting of change, and tolerant of the ambiguous and iterative nature inherent in the education change process. Many anticipated that some innovation would, or would at least deserve to, continue post- crisis. CONCLUSIONS: The COVID-19 pandemic afforded an opportunity to study the content and process of change during an active crisis. In this case of clinical education, our findings provide insight into the ways an academic medical system adapts to unanticipated circumstances. We found alignment with broader organizational change management models and that, compared with crisis management models (and their shorter term focus on resolving such crises), stakeholders self-organized in a reliable manner that carries the potential advantage of preserving such beneficial change.

Provider experience and satisfaction with a novel 'virtual team rounding' program during the COVID-19 pandemic.

BACKGROUND: New inpatient virtual care models have proliferated in response to the challenges presented by the coronavirus disease 2019 (COVID-19) pandemic; however, few of these programs have yet been evaluated for acceptability and feasibility. OBJECTIVE: Assess feasibility and provider experience with the Virtual Team Rounding Program (VTRP), a quality improvement project developed and rapidly scaled at Brigham and Women's Hospital in Boston, MA, in response to the surge of COVID-19 patients in the spring of 2020. METHODS: We surveyed 777 inpatient providers and 41 providers who served as 'virtual rounders' regarding their experience with the program. Inpatient providers were asked about their overall satisfaction with the program, whether the program saved them time, and if so, how much and their interest in working with a similar program in the future. Providers who had worked as virtual rounders were asked about their overall satisfaction with the program, the overall difficulty of the work and their interest in participating in a similar program in the future. RESULTS: We find that among both groups the program was well-received, with 72.5% of inpatient providers and 85.7% of virtual rounders reporting that they were 'satisfied' or 'very satisfied' with their experience with the program. Among inpatient providers who worked with the program, two-thirds reported the program saved them time on a daily basis. Inpatient respondents who had worked with virtual rounders were more likely to say that they would be interested in working with the VTRP in the future compared with respondents who never worked with a virtual rounder (75.3 vs 52.5%, P < 0.001). CONCLUSION: As the pandemic continues, rapidly implementing and studying virtual care delivery programs is crucial for hospitals and health systems. We demonstrate the feasibility and acceptability of a 'virtual rounding' program assisting inpatient providers. Future work should examine the impact of these programs on patient outcomes.

Virtual Team Rounding: A Cross-Specialty Inpatient Care Staffing Program to Manage COVID-19 Surges.

PROBLEM: The SARS-CoV-2 (COVID-19) pandemic presented numerous challenges to inpatient care, including overtaxed inpatient medicine services, surges in patient censuses, disrupted patient care and educational activities for trainees, underused providers in certain specialties, and personal protective equipment shortages and new requirements for physical distancing. In March 2020, as the COVID-19 surge began, an interdisciplinary group of administrators, providers, and trainees at Brigham and Women's Hospital created an inpatient virtual staffing model called the Virtual Team Rounding Program (VTRP). APPROACH: The conceptual framework guiding VTRP development was rapid-cycle innovation. The VTRP was designed iteratively using feedback from residents, physician assistants, attendings, and administrators from March to June 2020. The VTRP trained and deployed a diverse set of providers across specialties as "virtual rounders" to support inpatient teams by joining and participating in rounds via videoconference and completing documentation tasks during and after rounds. The program was rapidly scaled up from March to June 2020. OUTCOMES: In a survey of inpatient providers at the end of the pilot phase, 10/10 (100%) respondents reported they were getting either "a lot" or "a little" benefit from the VTRP and did not find the addition of the virtual rounder burdensome. During the scaling phase, the program grew to support 24 teams. In a survey at the end of the contraction phase, 117/187 (62.6%) inpatient providers who worked with a virtual rounder felt the rounder saved them time. VTRP leadership collaboratively and iteratively developed best practices for challenges encountered during implementation. NEXT STEPS: Virtual rounding provides a valuable extension of inpatient teams to manage COVID-19 surges. Future work will quantitatively and qualitatively assess the impact of the VTRP on inpatient provider satisfaction and well-being, virtual rounders' experiences, and patient care outcomes.

Accelerating Innovation in Health Care: Insights From a Qualitative Inquiry Into United Kingdom and United States Innovation Centers.

BACKGROUND: Digital health innovations are being prioritized on international policy agendas in the hope that they will help to address the existing health system challenges. OBJECTIVE: The aim of this study was to explore the setup, design, facilities, and strategic priorities of leading United Kingdom and United States health care innovation centers to identify transferable lessons for accelerating their creation and maximizing their impact. METHODS: We conducted qualitative case studies consisting of semistructured, audio-recorded interviews with decision makers and center staff in 6 innovation centers. We also conducted nonparticipant observations of meetings and center tours, where we took field notes. Qualitative data were analyzed initially within and then across cases facilitated by QSR International's NVivo software. RESULTS: The centers had different institutional arrangements, including university-associated institutes or innovation laboratories, business accelerators or incubators, and academic health science partnership models. We conducted interviews with 34 individuals, 1 group interview with 3 participants, and observations of 4 meetings. Although the centers differed significantly in relation to their mission, structure, and governance, we observed key common characteristics. These included high-level leadership support and incentives to engage in innovation activities, a clear mission to address identified gaps within their respective organizational and health system settings, physical spaces that facilitated networking through open-door policies, flat managerial structures characterized by new organizational roles for which boundary spanning was key, and a wider innovation ecosystem that was strategically and proactively engaged with the center facilitating external partnerships. CONCLUSIONS: Although innovation in health care settings is unpredictable, we offer insights that may help those establishing innovation centers. The key in this respect is the ability to support different kinds of innovations at different stages through adequate support structures, including the development of new career pathways.

Septic Arthritis and the Opioid Epidemic: 1465 Cases of Culture-Positive Native Joint Septic Arthritis From 1990-2018.

BACKGROUND: The clinical spectrum of septic arthritis in the era of the opioid crisis is ill-defined. METHODS: This is a retrospective chart review of 1465 cases of culture-positive native joint septic arthritis at Boston teaching hospitals between 1990 and 2018. RESULTS: Between 1990-2008 and 2009-2018, the proportion of septic arthritis cases involving people who inject drugs (PWID) rose from 10.3% to 20% (P < .0000005). Overall, methicillin-sensitive Staphylococcus aureus (MSSA) caused 41.5% of cases, and methicillin-resistant Staphylococcus aureus (MRSA) caused 17.9%. Gram-negative rods caused only 6.2% of cases. Predictors of MRSA septic arthritis included injection drug use (P < .001), bacteremia (P < .001), health care exposure (P < .001), and advancing age (P = .01). Infections with MSSA were more common in PWID (56.3% vs 38.8%; P < .00001), as were infections with MRSA (24% vs 16.8%; P = .01) and Serratia sp. (4% vs 0.4%; P = .002). Septic arthritis in the setting of injection drug use was significantly more likely to involve the sacroiliac, acromioclavicular, and facet joints; 36.8% of patients had initial synovial fluid cell counts of <50 000 cells/mm3. CONCLUSIONS: Injection drug use has become the most common risk factor for septic arthritis in our patient population. Septic arthritis in PWID is more often caused by MRSA, MSSA, and Serratia sp., and is more prone to involve the sacroiliac, acromioclavicular, sternoclavicular, and facet joints. Synovial fluid cell counts of <50 000 cells/mm3 are common in culture-positive septic arthritis.

Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services.

BACKGROUND: Paging still represents an important form of communication within hospitals, but it results in interruptions, and other more modern approaches could be superior. This study aims to describe how paging is currently used in an academic medical centre, including the frequency, type, urgency and sender of pages, so that improvements in communication can be better informed. STUDY SAMPLE: In order to understand what communication needs paging fulfils in a modern academic medical centre, we analysed a database of 1252 pages sent to internal medicine residents within an academic medical centre. We assessed all pages from 3 separate general medicine rotations over a total of 56 days encompassing 602 h. RESULTS: Residents were paged an average of 22.4 times per day, with a maximum of 50 pages per day. Most pages were deemed clinically relevant (76%) and important (76%) to patient care. Overall, 59% of pages required a response. A mean of 7.7 pages were sent per patient, up to a maximum of 70 pages for one patient. Nurses (28%), consultants (16%) and the clinical laboratory (15%) were responsible for the majority of pages. Almost all pages from nurses (82%) and consultants (82%) required a response. Regionalised services had significantly fewer pages per day than non-regionalised services (19 vs 37, p≤0.00001). CONCLUSIONS: Paging remains widely used for communications within hospitals about patient care. Although the majority of pages were judged to be clinically relevant and important, they frequently required a response potentially leading to interruptions in workflow, and communication waste. Paging rate and volume has not decreased in 25 years despite significant penetration of newer technologies. For the majority of current uses of pages, we believe other approaches may now be more appropriate. Regionalisation significantly reduces the number and urgency of the pages.

A mobile app for securely capturing and transferring clinical images to the electronic health record: description and preliminary usability study.

BACKGROUND: Photographs are important tools to record, track, and communicate clinical findings. Mobile devices with high-resolution cameras are now ubiquitous, giving clinicians the opportunity to capture and share images from the bedside. However, secure and efficient ways to manage and share digital images are lacking. OBJECTIVE: The aim of this study is to describe the implementation of a secure application for capturing and storing clinical images in the electronic health record (EHR), and to describe initial user experiences. METHODS: We developed CliniCam, a secure Apple iOS (iPhone, iPad) application that allows for user authentication, patient selection, image capture, image annotation, and storage of images as a Portable Document Format (PDF) file in the EHR. We leveraged our organization's enterprise service-oriented architecture to transmit the image file from CliniCam to our enterprise clinical data repository. There is no permanent storage of protected health information on the mobile device. CliniCam also required connection to our organization's secure WiFi network. Resident physicians from emergency medicine, internal medicine, and dermatology used CliniCam in clinical practice for one month. They were then asked to complete a survey on their experience. We analyzed the survey results using descriptive statistics. RESULTS: Twenty-eight physicians participated and 19/28 (68%) completed the survey. Of the respondents who used CliniCam, 89% found it useful or very useful for clinical practice and easy to use, and wanted to continue using the app. Respondents provided constructive feedback on location of the photos in the EHR, preferring to have photos embedded in (or linked to) clinical notes instead of storing them as separate PDFs within the EHR. Some users experienced difficulty with WiFi connectivity which was addressed by enhancing CliniCam to check for connectivity on launch. CONCLUSIONS: CliniCam was implemented successfully and found to be easy to use and useful for clinical practice. CliniCam is now available to all clinical users in our hospital, providing a secure and efficient way to capture clinical images and to insert them into the EHR. Future clinical image apps should more closely link clinical images and clinical documentation and consider enabling secure transmission over public WiFi or cellular networks.

User Perceptions of an mHealth Medicine Dosing Tool for Community Health Workers.

BACKGROUND: Mobile health (mHealth) technologies provide many potential benefits to the delivery of health care. Medical decision support tools have shown particular promise in improving quality of care and provider workflow. Frontline health workers such as Community Health Workers (CHWs) have been shown to be effective in extending the reach of care, yet only a few medicine dosing tools are available to them. OBJECTIVE: We developed an mHealth medicine dosing tool tailored to the skill level of CHWs to assist in the delivery of care. The mHealth tool was created for CHWs with primary school education working in rural Mexico and Guatemala. Perceptions and impressions of this tool were collected and compared to an existing paper-based medicine dosing tool. METHODS: Seventeen Partners In Health CHWs in rural Mexico and Guatemala completed a one-day training in the mHealth medicine dosing tool. Following the training, a prescription dosing test was administered, and CHWs were given the choice to use the mHealth or paper-based tool to answer 7 questions. Subsequently, demographic and qualitative data was collected using a questionnaire and an in-person interview conducted in Spanish, then translated into English. The qualitative questions captured data on 4 categories: comfort, acceptability, preference, and accuracy. Qualitative responses were analyzed for major themes and quantitative variables were analyzed using SAS. RESULTS: 82% of the 17 CHWs chose the mHealth tool for at least 1 of 7 questions compared to 53% (9/17) who chose to use the paper-based tool. 93% (13/14) rated the phone as being easy or very easy to use, and 56% (5/9) who used the paper-based tool rated it as easy or very easy. Dosing accuracy was generally higher among questions answered using the mHealth tool relative to questions answered using the paper-based tool. Analysis of major qualitative themes indicated that the mHealth tool was perceived as being quick, easy to use, and as having complete information. The mHealth tool was seen as an acceptable dosing tool to use and as a way for CHWs to gain credibility within the community. CONCLUSIONS: A tailored cell phone-based mHealth medicine dosing tool was found to be useful and acceptable by CHWs in rural Mexico and Guatemala. The streamlined workflow of the mHealth tool and benefits such as the speed and self-lighting were found to be particularly useful features. Well designed and positioned tools such as this may improve effective task shifting by reinforcing the tasks that different cadres of workers are asked to perform. Further studies can explore how to best implement this mHealth tool in real-world settings, including how to incorporate the best elements of the paper-based tool that were also found to be helpful.